Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2016

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VOID
CORRECTED
9494
TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
OMB No. 1545-1517
Distributions
country, ZIP or foreign postal code, and telephone number
From an HSA,
2016
Archer MSA, or
Medicare Advantage
MSA
1099-SA
Form
Copy A
PAYER'S federal identi cation number
RECIPIENT'S identi cation number
1 Gross distribution
2 Earnings on excess cont.
For
$
$
Internal Revenue
RECIPIENT'S name
3 Distribution code
4 FMV on date of death
Service Center
File with Form 1096.
$
For Privacy Act
and Paperwork
Street address (including apt. no.)
5 HSA
Reduction Act
Archer
Notice, see the
MSA
2016 General
City or town, state or province, country, and ZIP or foreign postal code
MA
Instructions for
MSA
Certain
Account number (see instructions)
Information
Returns.
1099-SA
Department of the Treasury - Internal Revenue Service
Form
41-0852411
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
VOID
CORRECTED
9494
TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
OMB No. 1545-1517
Distributions
country, ZIP or foreign postal code, and telephone number
From an HSA,
2016
Archer MSA, or
Medicare Advantage
MSA
1099-SA
Form
Copy A
PAYER'S federal identi cation number
RECIPIENT'S identi cation number
1 Gross distribution
2 Earnings on excess cont.
For
$
$
Internal Revenue
RECIPIENT'S name
3 Distribution code
4 FMV on date of death
Service Center
File with Form 1096.
$
For Privacy Act
and Paperwork
Street address (including apt. no.)
5 HSA
Reduction Act
Archer
Notice, see the
MSA
2016 General
City or town, state or province, country, and ZIP or foreign postal code
MA
Instructions for
MSA
Certain
Account number (see instructions)
Information
Returns.
1099-SA
Department of the Treasury - Internal Revenue Service
41-0852411
Form
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
VOID
CORRECTED
9494
TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
OMB No. 1545-1517
Distributions
country, ZIP or foreign postal code, and telephone number
From an HSA,
2016
Archer MSA, or
Medicare Advantage
MSA
1099-SA
Form
Copy A
PAYER'S federal identi cation number
RECIPIENT'S identi cation number
1 Gross distribution
2 Earnings on excess cont.
For
$
$
Internal Revenue
RECIPIENT'S name
3 Distribution code
4 FMV on date of death
Service Center
File with Form 1096.
$
For Privacy Act
and Paperwork
Street address (including apt. no.)
5 HSA
Reduction Act
Archer
Notice, see the
MSA
2016 General
City or town, state or province, country, and ZIP or foreign postal code
MA
Instructions for
MSA
Certain
Account number (see instructions)
Information
Returns.
1099-SA
Department of the Treasury - Internal Revenue Service
LSAA
5123
Form
41-0852411

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